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DECONSTRUCTING A DSM DIAGNOSIS2005). Axis I diagnoses can be quite serious, asthey include clinical disorders and developmentaland learning disorders. Another study examinedpsychological functioning in 13 FtM and 22 MtFtranssexuals in Belgium after their transitions.Although high rates of comorbid mental disorderswere found in both groups, higher rates emergedin the MtF group (De Cuypere, Jannes, & Rubens,1995).Of particular importance are comorbidpsychotic disorders such as schizophrenia. In thecurrent practice, an individual can be diagnosedwith both GID and schizophrenia (APA, 2000a, p.537). The relationship between the two disordersis complicated. Some individuals withschizophrenia have delusions involving genderchange (Borras, Huguenet, & Eytan, 2007).Maderson and Kumar (2001) described a case inwhich GID manifested along with schizophrenia.This is not to say that all individuals with GID arepsychotic; rather, it is presented as information toconsider when making diagnoses and treatmentrecommendations. It is unwise for a diagnosis tobe made during an acute psychotic episode, andcare should also be taken in the case of morechronic presentation.GID and Homosexuality: Parallel Diagnoses?Homosexuality was replaced in the DSMby ego-dystonic homosexuality in 1973, with thelatter subsequently being removed in 1986. Recallthat gender identity disorder of children (GIDC)and transsexualism were introduced in 1980,which laid the groundwork for the presentdiagnosis of GID. This timing led some critics tomake an intriguing argument that GID and itsrelated diagnoses were a covert way of “catching”individuals who would have been diagnosed withhomosexuality before 1973. A summary of thiscriticism in the literature, as well as a rebuttal,was provided by Zucker and Spitzer (2005).Some people draw parallels betweenhomosexuality and GID, arguing that GID shouldbe removed from the DSM because itpathologizes natural variance just as thehomosexuality diagnosis did (e.g. Ault & Brzuzy,2009). This is a view that is particularly endorsedby many activists. While this argument does havesome merits, it draws an oversimplified parallelbetween the two diagnoses. Homosexualitycannot be treated (APA, 2000b), but someindividuals with GID seek out and benefit fromtreatment. Thus, “while removal from the DSMled to a liberating and immediate ‘cure’ formembers of the gay community, a similarapproach with GID could have adverse treatmentconsequences, particularly for the anatomicallydysphoric transgender individuals seeking or inneed of medical transition” (Drescher, 2010, p.446). In other words, if hormones or surgery wereno longer medically necessary to treat a disorder,insurance coverage in some areas could cease.Although this may appear to be a mere practicalsnag, it would potentially have far-reaching andserious consequences. This is a concern that hasbeen echoed by non-psychologists invested in theissue. For example, Vance et al. (2010) surveyed43 organizations concerned with the welfare ofgender variant people. While 55.8% agreed thatGID should be excluded from the DSM V, thosewho thought it should be maintained cited healthcare reimbursement as the most common reason.In addition, Green et al. (2011) noted that thediagnosis can help establish legal identity rightsfor individuals with GID. Thus, removing thediagnosis would not be the simple cure that someactivists advocate for. Forty years after theremoval of homosexuality from the DSM, theissue of GID removal is still muddled and capableof eliciting passionate opinions among investedparties.SpecifiersAs seen in the previous section, sexualityand gender identity often cross paths in the DSM.Interestingly, sexuality is implicated in GID in adirect way through four specifiers: sexuallyattracted to males, females, both, or neither. Thespecifiers originally emerged in the DSM-IV(APA, 1994) and are based on work published byRay Blanchard (e.g., Blanchard, 1989; Blanchard,Clemmensen, & Steiner, 1987).Cohen-Kettenis and Pfafflin (2010) notedthat although no clinical decisions are based onthe subtypes, distinguishing between them may beuseful for research purposes. However, they also